Child and Adult Care Food Program (CACFP)
CERTIFICATE OF AUTHORITY
Agreement Number (if applicable):
This is to certify that
(Last) (First) (MI)
Date of Birth:__
_ _ Last 4 of SSN:
(MM/DD/YYYY)
IS DESIGNATED AS AN AUTHORIZED REPRESENTATIVE OF THE
(Name of Institution)
(Telephone Number)
(Street Address) (City, State, Zip)
(Signature of Authorized Person)
(Title)
Authority is hereby given to the above-designated representative to enter into an agreement, whether by handwritten or electronic signature, on
behalf of the above-named institution for the operation of the Child and Adult Care Food Program (CACFP) on all remaining forms for this
application and any other documents or reports relating thereto, including claims for reimbursement.
To obtain access to the CACFP application and claim system, please complete the following:
Check all that apply:
• Sponsor/Independent Center Application Yes No
• Provider/Site Applications Yes No
• Claims Yes No
E-Mail Address:
Answer ONLY ONE of the following security questions:
Mother’s maiden name? First pet’s name?
City were you born in? Favorite color?
Nonprofit Institution
BY: Tax ID: _______________________
(Signature of Executive Director/Board Chairman)
(Title) (Date)
For-Profit Institution
BY: Tax ID: _______________________
(Signature of Owner[s])
(Title) (Date)
By my signature above, I understand that the CACFP MUST be advised immediately of any change in authorized personnel and my designation
of the above-named representative does not relieve me of any liability for the mistakes, fraud, or any other illegal activity performed by the
designated representative in the name of or on behalf of the above-named institution.
PLEASE SUBMIT ONE FORM PER PERSON WITH SIGNATURE AUTHORITY
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